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General NPI Number Information
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NPI Number | 1487812392
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Entity Type | Organization
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Legal Business Name | DEREK S LONG OD INC
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Dates
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Enumeration Date | 05/28/2008
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Last Update Date | 05/24/2010
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Provider Practice Location Address
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Address Line | 4425 CENTRAL AVE STE B
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City | HOT SPRINGS
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State | AR
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Zip | 71913-7297
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Country | US
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Telephone | 501-525-0501
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Fax | 501-525-0628
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Provider Business Mailing Address
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Address Line | 115 AUDUBON DR STE 8
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City | MAUMELLE
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State | AR
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Zip | 72113-7409
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Country | US
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Telephone | 501-803-3937
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Fax | 501-803-3962
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Authorized Official
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Title or Position | DOCTOR
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Name | DR. DEREK S LONG
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Credential | OD
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Telephone | 501-803-3937
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 2547
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License Number State | AR
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